08060023 CITY OF CUPERTINO
BUIPERMITINdDIVIS104 PERT CLINTRACT(QRINFbRMATIO,IY
NO
Bu1L�I�+r�,�I�RE�,S:OLUMBUS AVE JUST WATER HEATERS INC 08060023
OWNER'S NAME: PERMIT ISSUE DATE
GRABER ROBERT K AND JOAN 3400 INVESTMENT BLVD 06/04/2008
(510) 293-9901 SANITARY NO, CONTROL NO.
ARCHITECM/ENGINEER: BUILDING PERMIT INFO
-BLDG EIFCT PLUMB MECH
0
sero LICENSED CONTRACTOR'S DECLARATION Job Description
m 1 hereby affirm that 1 am licensed under provisions e.SCrI of Chapter 9(commencing P
W with Secuon7OM))of Division3rfthe Buixuar ftresdou Codo,Wmy Rcenmis REPLC -50 GAL CTAS. WTR HTR
in full force and epect.
,23gE License Clans Lie.b .. ..
it:—p Dam Contractor
7W ARCHITECTS DECLARATION
s
U 1 undmwnd my plans shall Ise used u public retards
g G N Licensed Pmfcssional
3 OWNER-BUILDER DECLARATION
.� .Warm that hereby. Nat 1 em exempt Imre sex u
Crnitoh License Law for the0 0 0 following mamn.(Section 71D I.S. 4 mer, and improve.
derimi Code:Any cars or county
5_� which rcquissu Issuance,Man re cnnsrmL applicant
Improsu AemnlW, fl repair ed smumum
Z< dprior utW)is
endposant he ss,theNovisiocanf for such peninofierem Lmdsummem
(commencing
ncingwitpuwanllrNeOfDisiouofdteo,Box indProflaonsCrem9 Sq.Ft. Floor Area x�••995 Valuation
y kS•s (commencing pt t Section71)(a))and W,
the
theegeittexe and Professions Cade)of J
r3— S el io r exempt Nempoot and Ilse Eur for ube alleged exemption.he Any violation of
Soman 7031A by uryapdRantfor(3 permit subjects Ne,ppl¢mtnarnil Penalty of Number Occupancy Type
rpt msec th.n five hundred dollars atom. 35614032 .E P Y YP
L u wmer of 0m prvpesty,a mY esaploycet with wage u Nees role compewuon,
wiB Pr Nework and Ne he Camustur's kens Lawcld(,atom(Sec.TON,..rv.
and property
who
Cade:The Canrecmr's License law does ret apply b an owner is Required IIISPCCliODS
propertywho s.prsaImproves Mier and who doessuch wonthimselfed through h1.
mwemployers,prog or i pr suchimprovemanu arm not ear ofcrrrHesed rte tramer,
howeves,the building of improvement r mrd within arc year ofimproe for the rooemr-
Mi1des will have the Mssden of poring that he did ret build m improve for puryose of
sal'.).
0 1.as owner of the pmpony,iso exclusively convecting vied licensed mnuauom W
comvuct the project(Sec.TON.Business and Pmfessioru Code:)The Cono mores U.
come law does not apply m an owner of property who Milds or improves thereon,and.
who contuse for such pmjeces wits aeomrmmrts)Iicemsed pur eemi m IM ConoenWs
License Law.
O[macmplundes Sea ,BBPCrrrthrmasun '
Owner Dam
WORKERS COMPENSATION DECLARATION
1 hemby affirm under pevlly of perjury one of the following declensions:
I hsa and will maintain a Cmifrom ofCrmxnt in self-insure far Worker's Compere
sarion,u provided for by Sanson 3700 of the labor Code,for the performance of the
wort ser which this Permit is issued.
0 1 have arM will maintain Worker's Compensation Insurmso,Or required by Section
3700 of the labor Code,for the performance ofthe woh for which this permit us WOO& '
MY Worker's Compensation Insurance caries and Polic,number sore
Carrier Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Dtr aced.need ret M emnplevA if Ne Permit is i.e.bumdmd doBan($100)
or lest)
I certify thal in use pesfrrmsmc of the work Its which this Permit u issued,l shall not
employ any Nixon in my manrerm as to become subject to he Wrrkms'Con onsauon
Laws of California.Dam
AppBont
NOTICE TO APPLICANT.If,aper making this Cc,ificam of Exemption.you should
become subject an the Worteri Compceouon provisions of the labor Code,you most
.J Z fon6wiN comply with such provisions or this permit shall be deemed revoked.
z O CONSfRUCTIONLFNDINGAGENCY
PI Mreby allme NU Nem is a construction lending agency for the performence of
CL > the wort for which this Permit is issued(Sec.3097,Civ.C)
GQ tsndct's Name .
z fender's Address
U C) I tiafy N,I I Ease read We,ppfieauon and Ionic"Ne,bone irdmmeme,is
IA H comites.I agree m comply with all city and county m finances and stale laws relating m
0 Wilding construction.and hereby audeoriu mpresentatves ardor city to curer upon the
r W ,hose-menudgm propcst for inspection whryaus
4 (We)agree to nese,indemnify and keep harmless the City of Cupertino against
U Z
liabilitiesCms ,judg Of
—and expenses which may in anyway acme againslssid City
U z A APPLICANT
of Ne RSTting of dor D WILL
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
ONS.
ApplicanUmr Re-roofs
Conmxpare '
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a puled or(Muni Mal C g necopeck.Chapter
man handle buallou material
u dented by the Cupenim Municipal Code.Chapler 9.12 and the Heaith and Safety
code.se zss3z(.)T
❑y. ONO
All roofs shall be inspected prior to any roofing material being installed.
Yns
If a roof is installed without first obtainingan inspection,I agree to remove
Will to a1 exanst or fume Wilding by the B use o.Air co or devices which P g
emitict? es ser canumimnss u defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
P
❑Yes ON.
1 have read the haaaMmu mveriaia requirements under Chapter 6.95 of L e Califor-
.ia Hcalth h Safety Cade,sections,25505,25533 and 25534.1 uMentand that,ifthe Wilding
does rpt eWrendy ham a W'Iml that it is my me,su Niliry to Mtify de RSrpml of Nc
mquircrenm which most M met prior an ilium¢of a CoNfmme of acupancy, Signature Of Applicant Date
Owner or.umm.d.,cut p,m All roof coverings to be Class'%tx'or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35614032 . 00
DATE ISSUED. . . . . . . : 06/04/2008
RECEIPT #. . . . . . . . . : BS000004988
REFERENCE ID # . . . : 08060023
SITE ADDRESS . . . . . : 21891 COLUMBUS AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GRABER ROBERT K AND JOAN TRUST
ADDRESS . . . . . . . . . . : 21891 COLUMBUS AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4714
RECEIVED FROM JUST WATER HEATERS
CONTRACTOR . . . . . . . : GILROY, JOHN LIC # 15128
COMPANY . . . . . . . . . . : JUST WATER HEATERS INC
ADDRESS . . . . . . . . . . : 3400 INVESTMENT BLVD
CITY/STATE/ZIP . . . : HAYWARD, CA 94545
TELEPHONE . . . . . . . . : (510) 293-9901
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 995 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 . 48 0 . 00 24 . 48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 106 . 56 MC
TOTAL RECEIPT 10656 --
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
--------- ---------------------------- -------- ----------------------------
518 WATER HEATER
•
006 60, ,3
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 21891 Columbus Ave. Date: June 3, 2008
Owner's Name:---Robert Graybar
Phone No (408)253-3119
APN#: 356-14-032 00 Project Valuation .S 995.00
Building Permit Info: Bldg_____ Elect___- Plumb____ Mech---___
Job Description
Replace 50 gallon gas water heater.
Contractor Information
Company: Just Water Heaters Inc. Phone: (510)293-2012
• Contact Name: Fax: (510)293-2022
Address: 3400 Investment Blvd E-mail: permits®justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/10
Worker's Comp#: C45096282 Carrier: ACE Exp. Date: 4/l/09
Credit Card Information
Credit Card #: 5474-6390-0047-8660
Name on Card: dust Water Heaters Inc.
Expiration Date: 6/08
Visa MasterCard
Comments
Community Development
10300 Torre Avenue
_.
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
*CUPEkTINO
Building' Ike artment
JOB ADDRESS: PERMI #
21891 Columbus Ave. 0 Me d O
OWNER'S NAME: Robert Gra ber PHONE # 408-253-3119
GENERAL CONTRACTOR: JustW(a�t}er Heaters FAX # 510-783-6360
1 am not using any subcontractors: l`4e taL`a-%^ � 06/03/08
Signature Date
Please check applicable subcontractors and complete the following information:
Vj SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing Just Water Heaters 591329
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
U
• ,ato" 4-�a"` �Qx z�✓ -� 06/03/08
Owner/Contractor Signature Date
10/28/03